Dr. Mark Briesacher: Hi this is Dr. Mark Briesacher. I am here today with Dr. David Hasleton, and Dr. David Skarda. Dr. Hasleton is an ER physician, one of our physician leaders on the hospitals, and Dr. Skarda is a pediatric surgeon. Of course, with me being a pediatrician, we share that in common. We'll even include Dr. Hasleton, because he takes care of kids, too, in the ER.

We've all met through our work at Intermountain, various projects brought us together, usually projects around hey, how to make care better, how to make it safer, and advance quality and increase access, make it more affordable, all sorts of good things. I've had the great pleasure of getting to know the two of you, and to work with you. I'm glad we're here today and a whole bunch of other people are now going to get to know you as we talk about this really important topic, and that is our opioid crisis here in Utah and really, across the country.

I think when we talk to friends and families and our neighbors, people we know, you don't have to go too far to find someone whose life has been touched by this particular healthcare crisis. This is a really important thing for us today. I thought maybe Dr. Hasleton, maybe you could start by talking a little bit about why are we doing this work?

Dr. David Hasleton: This is a very important project for us to work on, not just a project, but it's a culture change in who we are as prescribers. We owe this to our community, to our patients and their families. We owe it to each other as prescribers to do a better job of helping our patients live healthier lives. We started a process about a year ago to look at how we can do better in our prescribing patterns and habits.

Through the work of Dr. Skarda, which started a few years ago with surveys to patients, we found that about 40% of that which is prescribed is not used by patients and is excess, so to speak, laying out there in the community in medicine cabinets, and is an option for diversion and other areas for misuse. That's how we started, so we approached it from that angle, and then we rolled forward.

Dr. Mark Briesacher: We announced a pretty heady goal earlier this year in terms of what we're going to accomplish.

Dr. David Hasleton: Yeah, 40% reduction for acute pain prescribing, and that's a very key piece to understand. We're not talking about chronic pain medication here, or palliative care, or hospice, or cancer patients, we're really talking about that which is prescribed in the acute setting. We realize we're overprescribing, and we're trying to right-size that.

Dr. Mark Briesacher: Okay, so this is actually a point I've been sometimes confused about. It's not our patients who we're treating for chronic pain syndromes of all different types, there's a totally separate body of work to help and support them and care for them and make that care a better experience and safer, always advancing our knowledge in that space.

This is really, this 40% goal, is completely focused on how we manage pain after fractures, traumas, surgeries, so those types of episodes?

Dr. David Hasleton: That's correct.

Dr. Mark Briesacher: Okay, so Dr. Skarda, I'm really interested in this survey that you did with patients. Certainly when we're caring for people, and we're working with them on, "Hey, this is how we're going to manage this particular condition." Their voice, their views on this are really important, and it sounds like that's what you did.

Dr. David Skarda: Yeah, so you're exactly right. Many years ago, more than a decade, one of the urologic surgeons in the Intermountain system identified the opioid crisis very early on and did a brilliant project in his own clinic, in which he simply tried to find out how many doses of pain medication his patients were actually taking after the operation.

He did this simply by asking them when they came in to see him in post-op in his clinic how many doses they took. He had them fill out a little form, they fill it out, he kept track of it. He ended up publishing this in a peer-reviewed journal. Jay Bischoff was and is visionary in terms of identifying this historically as a problem long before I did, and long before many people did I think.

About four years ago he came to meet with me, and explained what he felt was a critical problem, this opioid epidemic, and told me what he had found by doing this small study in his clinic, and impressed on me the need to understand better about how many doses our patients are actually taking post-op.

The reason why this is important, is because as I talked with surgeons system wide about our opioid prescribing process and our patterns and our habits about doing this, what they told me is they said, "We pretty much understand that we are giving more doses than patients are taking. We want to decrease that number of doses, we just don't know how many doses patients are actually taking. If we knew that number of doses, that's how many we'd give."

About a year and a half ago we put together a survey designed to ask patients who have had an operation in the Intermountain system how many doses of the opioid pain prescription they actually took postop. We started sending that out in early January 2017, and to date we've sent out about 80,000 surveys to patients system wide.

We have a response rate of around 30%, and what we've found is that if you look at the number of doses that patients get prescribed, on average they actually take somewhere around 20% to 40% of those, and that more than 60% usually goes unused and ends up in their medicine cabinet. What we've done now over the last six months or so, is we've utilized this data regarding consumption, and not prescription, but actual consumption data, and we have made recommendations for our most commonly performed procedures in the system regarding the number of doses that we should prescribe.

The way we're doing this, is we are taking the mean, or in some cases the median number of doses that patients take postop, and we are recommending that surgeons for patients who have that procedure, get two prescriptions. The first prescription being the number of doses that patients actually take, and then a second prescription to be filled no sooner than two to three days after discharge for the same number of doses.

What that means is that, for example, if somebody historically was taking 100 tablets, or getting a prescription for 100 tablets postop, our data would suggest in most cases they were taking somewhere around 25 to 35 of those. Our recommended number of doses would be 30, and patients would get two prescriptions. What we know now having done this for several months, is that most patients, 95% of patients only fill the first prescription.

What that means, is that historically these patients would've received 100 tablets, and had 70 in their cabinet. Now they're receiving 30, and they may have two or three or five extra, that's it. There's a small percentage, about 5% that I mentioned that actually fill that second script and use those, and there's a very small percentage, about 1% to 2%, that use that full second script and go back and need more pain medication.

As we've discussed this in retrospect now, and we speak with patients about the experience, there are some critical issues of this that I think we recognized beforehand going into this as at least really potentially strong benefits of this process. I think we underestimated how big a deal they actually were. When physicians write this two script model and have a critical discussion with patients, they do this discussion usually preop.

Essentially explain a couple of things, they explain number one, postoperatively there will be some pain after the operation. Operations hurt, number two, our goal is, is that they are as comfortable as possible. Number three, we want to give them enough pain medication to make sure they're comfortable, but not so much that they have a lot left over.

Patients love this discussion, the whole concept of number one, understanding that we are deeply committed to ensure that they are comfortable. Number two, we now have an idea how many doses we think they're actually going to take. This is an extraordinary conversation to have with patients where we can say, "Hey, you're going to have your gallbladder out today. In the Intermountain system, we know that 70% of patients take less than this number of doses, so we're going to give you this number."

Dr. Mark Briesacher: Dr. Skarda, can I ask you a question on this?

Dr. David Skarda: Yes.

Dr. Mark Briesacher: This question has been asked to me as I've gone around the system and talked with many providers. We have some patients, many patients who are already used to taking opioids.

Dr. David Skarda: Right.

Dr. Mark Briesacher: How then do you differentiate those who are opiod naïve, versus those are opioid exposed? How do you provide information to a prescriber? How do you help them educate their patients around how many doses are appropriate?

Dr. David Skarda: Yes, that's a really savvy question. We've always believed that those patients who have been taking opioids chronically before an operation, are more likely to take more postoperatively. However, the beautiful thing about this survey that we've done, is that it demonstrates for patients who were taking opioids before the operation, they do actually take more post-op.

We can define in our survey, based upon patient responses, and identify exactly which patients were taking more before the operation. We can actually give and have given recommended number of doses based upon whether or not the patient was taking opioids before the operation or not. The difference is not massive, it's not as if patients who were taking opioids before the operation take twice as many.

The difference is closer to maybe 15 if they weren't taking opioids before, and 20 if they were taking opioids before. One of the critical messages that we have attempted to communicate system wide to physicians and surgeons, is that it's critical as we're writing that postop script that we understand whether or not patients were taking opioids before the operation. That we alter the way we prescribe opioids for those patients when we know that they are.

The recommended number of doses that we have out there for every procedure that we do in the system, we actually have two recommendations. One for our opioid naïve patients, and a second recommendation for those patients who were taking opioids before the operation.

Dr. Mark Briesacher: It sounds, I suspect, that the two of you have had a lot of conversations about this with surgeons and physicians in the ED and other places. What are you hearing from them? How did you get their ideas and their input? We have such great physicians and surgeons who have all this experience, have cared for many, many people, providing amazing care and getting great outcomes.

You are coming in with this idea of changing how they have done that care. How did you hear from them, and actually how did their experience and ideas modify your thoughts and get to this solution?

Dr. David Hasleton: What we've found with our prescribers, we've had a lot of good response from those individuals who have viewed their data and had those aha moments of, "Maybe I am overprescribing, or maybe I need to do something different." It's been a beautiful thing to watch physicians make changes, and they feel really good about it, because they feel empowered to make that decision based upon data.

Dr. David Skarda: Yeah, from the surgery side every aspect of our opioid stewardship project came from clinically active clinicians system wide who simply came to us with a desire to help correct this. From the concept of doing the survey, to our current recommendations, all these come directly from clinicians. As we've now taken this message out using the data that we've collected to physicians, what we find is that from time to time we encounter physicians, most of the time we find physicians who are very interested and adopt this immediately.

From time to time we have physicians who are reluctant, who are concerned that the number we're recommending is well below the number that they have historically prescribed. That they're going to have patients calling frequently for refills with pain control issues, etc. Invariably, what we find from even the most resistant, reluctant physicians, is that number one, their patients love this conversation, and that the recommendations work.

Dr. Mark Briesacher: I recall reading a study not too long ago that talked about the effectiveness of other modalities beyond prescription for an opioid pain reliever, even comparing Tylenol, acetaminophen, to opioid prescriptions. That got me thinking about the other ways to manage pain, has that been part of the conversations with the surgeons and the ED docs?

Dr. David Hasleton: Dr. Briesacher, you ask a very good question, and it has been part of the discussion. We don't have a lot of great answers right now other than we know that other modalities work, and these are areas that we're exploring, such as acupuncture. We know that it does work in some areas, but it's not well studied yet. We know that there's a mindfulness, there are studies ongoing, even one at the University of Utah right now, of doing other things that involve thoughts and mindfulness and understanding what the problem is, rather than taking pills.

Dr. David Skarda: Yeah, so on the surgery side there are really two components to this answer. Number one, when we prescribe pain medication, we have created essentially a dialogue that physicians can use with their patients, in which we recommend that they initially attempt pain control with a combination of Tylenol and ibuprofen, warm packs, cold packs, elevation, all of the non-opioid modalities that we know work most of the time.

We then provide the patient with a prescription that they can fill if those modalities do not work. More than 50% of patients actually do fine and do not use the opioid altogether. The other way, and the other important way to think about the answer to this question, is at least for the surgical patients who are having some type of operation, we have a unique opportunity with those patients to manage their pain up front in a way that allows us to control pain beforehand, and limit the amount of opioids that they need after the operation.

Specifically as a patient's getting ready to go to the OR in preop in the Intermountain system right now, we are recommending that those patients get a dose of Tylenol. They get oftentimes a single dose of an opioid by mouth as they're wheeling back for the operation. Once they get back into the operating room, we're giving them some steroids for nausea, again, this symptom control.

We're giving them a dose of Toradol in the operating room, oftentimes we're giving them some other modalities such as ketamine, magnesium infusions, lidocaine infusions are being used in some of our locations. We are working very hard to essentially preload patients with pain control options, multi-modality therapy, so that when they wake up after the operation, they don't have as much pain, and they don't need that initial opioid dose.

More often than not we can keep them off opioids altogether. We are working towards an opioid free surgical system.

Dr. Mark Briesacher: I'm just impressed and not surprised that so many people are thinking about how to address this challenge that we have. I wonder if you could share what I'm sure are one of maybe hundreds of amazing stories that you have heard or experienced in this work over the past 12 months, I don't know if Dr. Hasleton?

Dr. David Hasleton: Yeah, there are a number of stories, and this touches many, many lives. I met an individual in Provo who has a brother who is addicted to opiates. I'm speaking on the chronic side of things, but it started out with a very simple accident and injury, for which this patient received opiates. Now fast forward five years, and he's still on opiates.

This was never where he wanted to be, a very high functioning individual, has a job, has a family, but the opiates has affected both of those. What he decided to do with the help of his family and some good practitioners, very professional people, it took him several months to wean off of it, and then he actually went through and destroyed the last parts of his opiates in a very good manner.

It was a very dramatic effect for him, but had a very profound effect on his family. The individual that I know down in Provo came back to me to relay this story to me. It was impressive to see how it now affected this individual and his family, but extended family. You have a lot of happy people out there, because Intermountain healthcare and other professionals have decided to take this on as a community health benefit.

Dr. Mark Briesacher: Dr. Skarda, what about on the surgeon side.

Dr. David Skarda: Yeah, so we believe very strongly that opioids prescribed after a surgical procedure often function as a gateway for patients to initially have their initial exposure to opioids, and then as Dr. Hasleton mentioned, this can oftentimes lead to chronic opioid utilization. We now estimate that close to 40% of the surgical operations, the surgical procedures that we do in the system, occur and patients do not take any opioids postop.

We believe this will have a very critical, massive long-term effect on preventing chronic opioid consumption in our population.

Dr. Mark Briesacher: I want to thank the two of you for having the courage to take this on. The leadership that you're providing, the way you are listening to our surgeons, our physician colleagues in figuring out how to always get better at this. The way that you're partnering with other leaders across the system, and we could fill the room up with physicians, nurses, advanced practice clinicians who feel really strongly about this topic and are contributing to making it better.

Most importantly our patients in our communities, they're going to be very thankful about this, and I think they already are, I know they are. The future here, though, is what we're aiming for, and I'm glad you're on the team, thanks for being here.

Intermountain Healthcare is a Utah-based, not-for-profit system of 24 hospitals (includes "virtual" hospital), a Medical Group with more than 2,400 physicians and advanced practice clinicians at about 160 clinics, a health plans division called SelectHealth, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery.